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Patient Referral Form

We believe in a team-focused approach to veterinary medicine. Working with referring veterinarians helps us maintain patient care standards and provide client service. While we work on dermatologic and allergy concerns for our patients, we expect that routine veterinary services (health check-ups, vaccinations, etc.) will continue to be provided through the primary veterinarian.

To refer a patient, please complete and submit the Patient Referral form, either online or by fax or e-mail. We encourage you to give us a call or email us before submitting your Patient Referral if you have any questions or concerns. Our Reception Team will be happy to answer any booking or clinic policy related questions. If you have medical questions about the case you are referring, one of our experienced Dermatology Technicians will address your inquiries as best they can in preparation for the initial appointment.

Once the referral has been received, a vet dermatologist consultation will be scheduled with the pet owner. Following the consultation, we will communicate with the primary veterinarian’s office directly in order to provide a complete record and referral report of your patient.

OWNER INFORMATION:
REFERRING VETERINARIAN INFORMATION
Desired method of referral report delivery:
STATUS OF REFERRAL
PATIENT INFORMATION
Heart Murmur / Grade
FAS Score

*Please note, pre-visit pharmaceuticals including Gabapentin and Trazodone, do not interfere with dermatology assessment or allergy testing. If the patient requires anti anxiety medication for examination, please provide to client prior to the initial consultation.
Primary Reason for Patient Referral:
Case Summary:
Medications / Treatments and Response to therapy:
Diagnostics, Treatments and Response to therapy:(Please attach any diagnostic or laboratory reports)
Special Requests or Expectations:

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